The nurse anesthetist’s perception of the role of case manager in four provinces of Indonesia

Abstract

Introduction

Integrated and patient-focused healthcare is urgently needed, and there is an important role for case managers in implementing them. However, the understanding of healthcare providers, especially nurse anesthetists, about the role of case managers is still varied and is often considered only as a complement to hospital accreditation. This study aimed to determine the factors that influence the nurse anesthetist’s perception of the role of the case manager.

Methods

This cross-sectional study involved 369 nurse anesthetists who were selected using cluster sampling. Data collection was done using Google Forms. Furthermore, the data were analyzed using multiple logistic regression to identify the factors that influence the nurse anesthetists’ perception of the role of the case manager.

Results

From a total of 369 respondents, most (60%) have a positive perception of case managers. Marital status (AOR = 2.3; 95% CI: 1.27–4.15) and knowledge (AOR = 3.2; 95% CI: 2.03–5.07) were significant predictors of the nurse anesthetist’s perception of the role of the case manager.

Discussion

Even though the majority of nurse anesthetists have positive perceptions, socialization to increase knowledge about case managers is needed to reduce misperceptions about the role of case managers.

Keywords

Cross-sectional studies case managers nurse anesthetists perception

Introduction

Patient-focused health services develop and run synergistically between health and non-health professional disciplines when they are balanced with integrated service management. The case manager is an important role in the successful implementation of this integrated service. Case managers can work with a multidisciplinary team and closely with individuals and families to understand the disease at hand, determine what to do to participate with the clinical team, and follow the treatment plan to achieve the best results.¹

Globally, the implementation of case managers is still experiencing some problems. Case managers allocate the largest proportion of time to care coordination (22.0%) and the smallest proportion of time to outcome evaluation (8.0%).² This can be seen in the fact that all case managers carry out all of their functions and duties, but not all those involved in discharge planning carry out post-discharge follow-ups with patients.³ In one study, the majority of case managers had not created a discharge planning program (66.6%); had not implemented an effective plan for patient flow (57.1%); had not attended training to achieve certification (74%); did not document activities in Forms A and B (71.4%). Form A contains notes about patient questions or screening, assessments, problems, and plans made by the case managers. Meanwhile, form B contains notes on the implementation of the role of case managers such as monitoring, facilitation, coordination, communication and collaboration, advocacy, service outcomes, and termination; did not carry out discharge planning (76.6%); and did not monitor post-treatment controls on patients (61.9%).⁴

It is imperative that there is good coordination by the case manager in terms of follow-up care, as follow-up after the patient is discharged from the hospital is very important to ensure that the care received by the patient is not interrupted or that the patient does not experience gaps in both hospital and home care. If case managers can carry out their roles effectively, they can improve the management of complex physical, psychological, and social problems.⁵ The presence of a case manager has also proven effective in improving the quality of health services on a national scale.⁶

Many factors are involved in the emergence of various understandings of a case manager. The most influential factor in the formation of nurses’ perceptions is knowledge.⁷ Factors of job satisfaction, education, and marital status were also associated with nurses’ perceptions. Nurses who are dissatisfied with their profession are 3.51 times more likely to have negative perceptions; nurses with diplomas and low levels of education are 2.65 times more likely to have negative perceptions; and unmarried nurses have a tendency to have negative perceptions at a rate that is 3.56 times higher than married nurses.⁸ Work fatigue also affects nurses’ perceptions.⁹ The factors of tenure, leadership, workload, knowledge, attitudes, and skills can also affect nurses’ perceptions.¹⁰ Meanwhile, age, gender, marital status, education, and work culture were not associated with nurses’ perceptions.¹⁰

Given the very important role of the case manager in health services, it is deemed necessary to minimize misperceptions about the case manager. The results of previous studies on the role of case managers vary, and there are limited specific studies regarding the perceptions of nurse anesthetists on the role of case managers, so this study aims to address this gap. The objectives of this study were divided into two, namely: (1) to assess the perceptions of nurse anesthetists on the role of the case manager and (2) to identify the determinant factors that influence the nurse anesthetist’s perception of the role of the case manager in Indonesia.

Methods

Setting

The healthcare system in Indonesia is divided into three levels (primary, secondary, and tertiary healthcare services). Primary healthcare services are provided by community health centers in the sub-districts, secondary healthcare services are provided by hospitals in the districts/municipalities, and tertiary healthcare services are provided by hospitals at the provincial level. Nationally, all healthcare systems are controlled by the Ministry of Health of the Republic of Indonesia. In addition, supervision of primary and secondary care services is carried out by the district health office, and tertiary healthcare services are supervised by the provincial health office.^11–13

Design

This study is a cross-sectional study conducted on nurse anesthetists in Indonesia.

Participants

There were 4741 registered nurse anesthetists in Indonesia (data on January 30, 2020)¹⁴ and the required 369 samples were calculated using Daniel’s sample size formula.¹⁵ Cluster sampling was performed, where four provinces (Aceh, Banten, Central Java, and East Nusa Tenggara Provinces) were selected using simple random sampling with a total of 898 registered nurse anesthetists. Finally, 369 registered nurse anesthetists from four provinces were recruited using simple random sampling. Inclusion criteria included nurse anesthetists working in government and non-government hospitals, being qualified as a nurse anesthetist, having a minimum of 3 months of service, and being willing to be research respondents. Nurse anesthetists assigned to outpatient or one-day care units were excluded.

Data collection

Data were collected from March 1, 2021 to June 5, 2021, using a seven-part questionnaire. The questionnaire was distributed via Google Forms to all respondents in the four provinces. Demographic characteristics: this data consisted of questions about gender, age, marital status, education, income, place of work, and years of experience. Perception: about the role of the case manager consisted of initial screening, planning, facilitation and advocacy, service coordination, and evaluation. These perceptions were measured using a Likert scale consisting of strongly agree, agree, undecided, disagree, and strongly disagree.¹⁶ The nurse anesthetist’s perception of the role of the case manager is categorized into two options, namely positive perception and negative perception.¹⁷ Knowledge: knowledge of case managers is measured using the Guttman scale which consists of true and false.¹⁸ In this study, knowledge about the role of the case manager consisted of 10 questions and 3 potential answers, namely true, false, and don’t know. The nurse anesthetist’s knowledge of case managers is categorized into two, namely low knowledge (<60%) and good knowledge (≥60%).¹⁹ Job satisfaction: the nurse anesthetist job-satisfaction section in this study consisted of 10 job-satisfaction factors (including salary, promotion, supervision, additional benefits, awards, procedures and regulations, coworkers, type of work, and communication). The answer choices used a Likert scale (very satisfied, satisfied, quite satisfied, dissatisfied, and very dissatisfied).²⁰ Furthermore, the nurse anesthetist’s job satisfaction was categorized into two, namely dissatisfied and satisfied.²¹ All parts of the questionnaire were tested for validity and reliability (Cronbach alpha >0.7). Work fatigue: work fatigue was measured using a standard questionnaire from the Industrial Fatigue Research Committee (IFRC), which consisted of 30 statements with a Cronbach alpha value of 0.921.²² Work fatigue in this study included attenuation of activities, weakened motivation, and physical attenuation, measured by a Likert scale consisting of never feeling, sometimes feeling, often feeling, and always feeling.²² The nurse anesthetist’s work fatigue was categorized into three, namely mild, moderate and severe work fatigue.²³ The three categories were then converted into two categories (mild and moderate or high) for analysis purposes.

Data analysis

Data entry and analysis was completed using SPSS (Version 20). Descriptive statistics (frequency and proportion) were used to measure the nurse anesthetist’s perception of the case manager, the chi-square test was used to analyze the relationship between the independent and dependent variables, and multiple logistic regression was used to identify the determinant factors that influence the nurse anesthetist’s perception of the case manager.

Ethical considerations

This study received ethical approval from the Ethical Clearance Committee of Research of the Institute of Technology and Health Bali (No. 04.0251/KEPITEKES-BALI/III/2021). The nurse anesthetists were asked to give consent to be a respondent via a link on Google Forms before filling out the questionnaire. If the nurse anesthetist indicated that they were not willing to be a respondent, they were not permitted to fill out the questionnaire.

Results

Characteristics of study participants

Table 1 shows that, of the 369 nurse anesthetists, the majority of nurse anesthetists are over 36 years old (53%), male (79%), married (84%), have a diploma (59%), earn high incomes (71%), work in a government hospital (76%), and have long tenure (56%).

Table 1.

General characteristics of the nurse anesthetist (n1 = 100, n2 = 100, n3 = 104, n4 = 65).

Characteristics	Total (n = 369)	Aceh	Banten	Central Java	NTT
Characteristics	n (%)	n1 (%)	n2 (%)	n3 (%)	n4 (%)
Age (years old)
≤36	172 (47)	59 (59)	30 (30)	40 (39)	43 (66)
>36	197 (53)	41 (41)	70 (70)	64 (61)	22 (34)
p-value	0.089
Gender
Male	291 (79)	83 (83)	83 (83)	77 (74)	48 (74)
Female	78 (21)	17 (17)	17 (17)	27 (26)	17 (26)
p-value	0.682
Married status
Unmarried	58 (16)	18 (18)	10 (10)	17 (16)	13 (20)
Married	311 (84)	82 (82)	90 (90)	87 (84)	52 (80)
p-value	0.006
Education level
Diploma	218 (59)	78 (78)	40 (40)	48 (46)	52 (80)
Bachelor’s or above	151 (41)	22 (22)	60 (60)	56 (54)	13 (20)
p-value	0.037
Monthly income
Low	13 (4)	5 (5)	3 (3)	3 (3)	2 (3)
Moderate	92 (25)	28 (28)	25 (25)	24 (23)	15 (23)
High	264 (71)	67 (67)	72 (72)	77 (74)	48 (74)
p-value	0.116
Place of work
Public hospital	282 (76)	77 (77)	75 (75)	83 (80)	47 (72)
Private hospital	87 (24)	23 (23)	25 (25)	21 (20)	18 (28)
p-value	0.968
Years of experience
≤10 years	161 (44)	53 (53)	33 (33)	38 (36)	37 (57)
>10 years	208 (56)	47 (47)	67 (67)	66 (64)	28 (43)
p-value	0.073

Perception about the role of the case manager

Figure 1 shows that, out of 369 nurse anesthetists, 222 nurse anesthetists have a positive perception of the role of the case manager and 147 nurse anesthetists have a negative perception of the role of the case manager. Nurse anesthetists’ perceptions of the role of case managers in the four provinces, namely Aceh, Banten, Central Java, and NTT, have almost the same percentage of positive perceptions (58%, 60%, 60%, and 65%, respectively). Likewise, the proportion of positive perceptions in total is 60%, which shows that most respondents have positive perceptions of case managers.

Figure 1.

Perceptions of the nurse anesthetist on the role of the case manager (n1 = 100, n2 = 100, n3 = 104, n4 = 65).

Knowledge, job satisfaction, and burnout

Table 2 describes the knowledge, job satisfaction, and burnout of 369 nurse anesthetists. Regarding knowledge, the majority of nurse anesthetists have low knowledge of case managers (58%), with the highest being in NTT (62%). Regarding job satisfaction, the majority of nurse anesthetists have job satisfaction, with 52% in the satisfied category, and the highest satisfaction being in Central Java (54%). Regarding burnout, most of the nurse anesthetists had a moderate level of burnout (81%), with the highest percentage being in Banten (83%).

Table 2.

Knowledge, job satisfaction, and burnout among nurse anesthetists (n1 = 100, n2 = 100, n3 = 104, n4 = 65).

Factors	Total (n = 369)	Aceh	Banten	Central Java	NTT
Factors	n (%)	n1 (%)	n2 (%)	n3 (%)	n4 (%)
Knowledge
Poor	214 (58)	61 (61)	59 (59)	54 (52)	40 (62)
Good	155 (42)	39 (39)	41 (41)	50 (48)	25 (38)
p-value	<0.001
Job satisfaction
Unsatisfied	178 (48)	49 (49)	50 (50)	48 (46)	31 (48)
Satisfied	191 (52)	51 (51)	50 (50)	56 (54)	34 (52)
p-value	0.106
Burnout
Low	298 (81)	81 (81)	83 (83)	83 (80)	51 (79)
Moderate	68 (18)	19 (19)	17 (17)	18 (17)	14 (21)
High	3 (1)	0 (0)	0 (0)	3 (3)	0 (0)
p-value	0.255

Determinant factors that affect the perception of the role of the case manager

A multivariate analysis of factors relating to the nurse anesthetist’s perception of the role of the case manager is presented in Table 3. Nurse anesthetists who were married during the course of the study were 2.3 times more likely to have a positive perception of the role of case managers than those who were not married (Adj. OR: 2.3; 95% CI: 1.27–4.15; p 0.031). Nurse anesthetists who had good knowledge of the role of case managers were 3.2 times more likely to have a positive perception of the role of case managers than nurse anesthetists who had poor knowledge of case managers (Adj. OR:3.2; 95% CI: 2.03–5.07; p < 0.001).

Table 3.

Multivariate analysis of determinant factors influencing the nurse anesthetist’s perception of the role of case managers (n = 369).

Factors	Perception about the role of case managers		Adj. OR	95% CI	p-value
Factors	Positive, n (%)	Negative, n (%)	Adj. OR	95% CI	p-value
Married status
Unmarried^a	25 (43)	33 (57)
Married	197 (63)	114 (37)	2.3	1.27–4.15	0.006
Knowledge
Poor^a	105 (49)	109 (51)
Good	117 (76)	38 (24)	3.2	2.03–5.07	<0.001

Reference groups.

Discussion

The results of the current study found that the majority (60%) of nurse anesthetists had a positive perception of the role of the case manager. The perceptions of the role of the case manager in this study included initial screening, planning, facilitation and advocacy, coordination of services, evaluation, and post-discharge follow-up. Among the four provinces studied (Aceh, Banten, Central Java, and NTT), more than half of the nurse anesthetists had a positive perception of the role of case managers (58%, 60%, 60%, and 65%, respectively). As far as we know, no results have yet been published showing the nurse anesthetist’s perception of the role of the case manager. However, Lukersmith²⁴ states that case management still varied, thereby impacting the amount of confusion and ambiguity regarding the role of the case manager.

A positive perception of the role of the case manager means that the nurse anesthetist has a good understanding of the role of the case manager, including the case manager’s role in initial screening, planning, facilitation and advocacy, coordination of services, evaluation, and post-discharge follow-up. The existence of this positive perception is very important in order to improve coordination and communication between nurses, healthcare workers, and management, which is facilitated by the case manager. It also has an impact on improving the quality of the anesthetic nursing care provided, thereby increasing patient and family satisfaction and involvement in the recovery process, which leads to reduced readmissions and improved quality of services.^25,26

This current study reveals that marital status has a significant effect on the nurse anesthetist’s perception of the role of the case manager. It was found that nurse anesthetists who were married usually have more positive perceptions of the role of the case manager, as compared with nurse anesthetists who were not yet married. This may be because the nurse anesthetists who are married are having a maturity of thinking and understanding related to the case manager’s perception. The maturity in thinking possessed by married nurse anesthetists manifests as logical and rational thinking patterns. This provides them with problem-solving skills and allows them to be more precise in perceiving something. In addition, the higher perception and better satisfaction are related to the positive attitudes of nurses.²⁷ The findings in this current study are in line with the research on factors related to nurses’ perceptions of nurse caring behavior in Ethiopia, which found that married nurses tend to have more positive perceptions.⁸ However, this study is different from research on the effect of individual characteristics and capabilities as well as organizational characteristics on nurses’ performance perceptions in Palembang City, which found that marital status was not related to nurses’ perceptions.¹⁰

The current study reveals that knowledge also has a significant relationship with the nurse anesthetist’s perception of the role of the case manager. This study also revealed that nurse anesthetists who have good knowledge of case managers tend to have more positive perceptions about the role of case managers, as compared with nurse anesthetists who have poor knowledge. In this study, it was also found that knowledge was the most influential factor in the nurse anesthetist’s perception of the role of the case manager. The existence of good knowledge about case managers encourages someone to engage in the mapping (selection), so that unnecessary or unimportant information is deleted or generalized, and does not lead to biased perceptions that trigger misunderstandings. Socialization to increase knowledge about case managers is needed to reduce misperceptions about the role of case managers.

The results of the current study are in line with research on knowledge and perception of radiation risk for nursing students after the Fukushima Nuclear Power Plant disaster in Japan, which found that there was a relationship between knowledge and perception.²⁸ The existence of adequate knowledge can improve understanding and minimize the occurrence of misperceptions. Other studies on risk perception and level of disease knowledge also found similar results. One study found that health workers with low knowledge have a low-risk perception.²⁹ Another study on health professionals’ knowledge and perceptions of influenza vaccines in Saudi Arabia also found that knowledge was positively correlated with perceptions.³⁰

The findings in the current study are not in line with the research on the effect of education level on the perception of social and spontaneous smiles, which found that education level can affect perceptions.³¹ This current study is also not in line with research on nurses’ perceptions of patient safety culture, which also finds that nurses’ perceptions are influenced by education.³² The current study is also different from the research on the factors related to nurses’ perceptions of caring behavior of nurses in Ethiopia, which found that nurses with diplomas and low levels of education tend to be more likely to have negative perceptions.⁸ The higher the level of education, the more knowledge, and ability to think critically, so there is more precision in perceiving something. Another study on nurses’ perceptions of health literacy in Saudi Arabia also found different results. The study found that the level of education was related to nurses’ perceptions.²⁴ Meanwhile, in this current study, education is not related to perception, possibly because nurse anesthetists are generally less exposed to information about the role of case managers, therefore most of them have poor knowledge in terms of case managers.

The current study reveals important findings about the nurse anesthetist’s perception of the role of the case manager and the factors that influence it because as far as we are concerned, the publication of the findings of this study is the first in Indonesia. Furthermore, these findings are very important and can be considered to increase the knowledge and perception of the nurse anesthetists on the role of the case manager, as well as to improve the quality of anesthesia nursing services. There are several weaknesses in the current study. First, online data collection causes researchers to not be able to observe respondents directly in filling out the questionnaire. Second, this study used cross-sectional data; therefore, causal relationships cannot be inferred.

For further studies, it is very important to continue this research by (1) increasing the number of provinces with multistage random sampling; (2) conducting qualitative research to explore the perceptions, challenges, and barriers of nurse anesthetists in carrying out their role as case managers; and (3) combining both quantitative and qualitative approaches or known as mixed methods study.

In conclusion, this study found that most (60%) nurse anesthetists had a positive perception of the role of the case manager. Marital status and knowledge are factors that influence the nurse anesthetist’s perception of the role of the case manager in the four provinces of Indonesia. Socialization about case managers and the role of case managers to nurse anesthetists is very necessary to increase their knowledge, so that their perception of the role of case managers becomes better, and be able to improve the quality of anesthesia nursing services in hospitals.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Ni Luh Putu Lusiana Devi

I Ketut Swarjana

Ni Putu Ayu J. Sastamidhyani

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